Form 41

(See rule 106)

APPLICATION FOR THE SITE APPRAISAL COMMITTEE

1. Name and address of the applicant.

2. Site Ownership Data

(1) Revenue details of the site such as Khasra No. Plot No.

(2) Local authority under whose jurisdiction the site is located.

3. site plan with clear identification of boundaries and total area proposed to be occupied

and showing details nearby the proposed site

(a) Name of adjoining manufacturing units and human habits, educational and training

institutions. Petrol installations, storages liquefied Petroleum Gas and other

hazardous substances, if any, within one kilometer from the proposed unit.

(b) Water sources (rivers, streams, canal dams, water filtration plants) in the vicinity.

(c) Nearest hospitals, Fire-stations, Civil Defence Stations and Police Station and their

distances.

(d) Details of high tension electrical transmission lines, pipe lines for oil, gas sewerage, if

any, passing through the site, and

(e) Location of railway stations, railway lines, Scheduled road, byepass, if any near the

site.

4. Project Report.

(1) A summary of the salient features of Project.

(2) Mazimum number of persons like be working in the factory.

(3) maximum amount of power and requirements and source of supply.

(4) Details of housing colony, hospital, school and other infrastructural facilities

proposed.

5. Organisation structure of the proposed manufacturing unit/factory.

6. manufacturing Process information

(1) Process flow diagrams.

(2) Brief write up on process and technology; and

(3) Critical Process parameters such as pressure build-up, temperature rise and run-away

reaction.

7. Information of Hazardous materials.

(1) Raw Materials intermediates, products and byproducts and their quantities (enclosed

Material Safety Data Sheet in respect of each hazardous substances.

(2) main and intermediate storages proposed far raw material/intermediates/products/Bye

Products (maximum quantities to be stored at any time)

(3) Transportation methods to be used for materials in flow and out flow, their quantities

to be stored at any time, and

(4) Safety measures proposed for:

…………….. handing of materials.

…………….. internal and external transportation, and

…………….. disposal (packing and forwarding of finished products)

8. Information of Dispersal/Disposal of wastes and pollutants

9. Process hazards Information

(1) Enclosed a copy of the report on environmental impact assessment.

(2) Enclosed a copy of the report an Risk Assessment study : and

10. Information of proposed Safety and Occupational Health measure;

11. Any other information:

I certify athat the information furnished above is correct to the best of my knowledge

and nothing has been concealed while furnishing it

Signature

Date

Designation